Failure to Use Mechanical Lift During Post-Fall Transfer
Penalty
Summary
Staff failed to properly transfer a resident following a fall in her room. The resident, who had mild cognitive impairment and multiple diagnoses including dementia and PTSD, was found on the floor by a CNA after attempting to reach for water and falling out of bed. The resident complained of significant hip pain and was unable to straighten her leg without pain. Despite these complaints, the CNA and an LPN lifted the resident from the floor back to her bed by placing their arms under her arms, rather than using a mechanical lift as required by facility policy and as later confirmed by the Director of Nursing. Staff statements and interviews confirmed that the resident expressed pain during the transfer and was unable to move her leg, yet the mechanical lift was not used. The facility's policy instructed staff to assess the resident and safely transfer them using appropriate equipment after a fall, but this was not followed. The incident was documented in progress notes and staff statements, and the Director of Nursing acknowledged that the correct procedure was not used in this situation.